Summary of Benefits

You have options for your Medicare Advantage coverage. Think about your needs and what type of benefits will help you most. Keystone First VIP Choice (HMO SNP) offers all the benefits of regular Medicare, plus more.

The EOC tells you how to get Medicare medical care and prescription drugs through our plan. The booklet explains what's covered, how much you'll pay for services, and all about your rights and responsibilities.

The comprehensive dental benefit covers minor restorations (fillings), simple extractions, dentures, and denture repair up to $1,000 every two years. Periodontics, endodontics, oral maxillofacial surgery, and other prosthodontics are not covered services.

Hearing exams and aids

$0 copay for Medicare-covered diagnostic hearing exams.

$0 copay for up to one routine hearing exam every year.

$0 copay for one fitting evaluation for a hearing aid every three years.

$0 copay for up to one hearing aid every three years.

$1,000 every three years for hearing aids for both ears combined.

Vision services

$0 copay for Medicare-covered diagnosis and treatment for diseases and conditions of the eye, including an annual glaucoma screening for people at risk.

One pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery.

$0 copay for the following preventive vision benefits:

Up to one routine eye exam every year.

Up to one pair of eyeglasses (lenses and frames) every two years.

Up to one pair of contact lenses every two years.

We pay up to $200 every two years for contact lenses and eyeglasses (frames and lenses).

Transportation

$0 for up to 30 one-way trips to plan-approved locations every year. May consist of car, shuttle, or van service depending on appropriateness for situation.

Scheduling rules apply.

Over-the-counter (OTC) items

You may spend up to $70 per quarter for items from our OTC catalog. Money not spent in a quarter does not roll over into the next quarter.

Home health care

$0 copay for Medicare-covered home health visits.

Outpatient mental health care

$0 copay for each Medicare-covered individual therapy visit.

$0 copay for each Medicare-covered group therapy visit.

$0 copay for each Medicare-covered individual therapy visit with a psychiatrist.

$0 copay for each Medicare-covered group therapy visit with a psychiatrist.

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Keystone First VIP Choice (HMO SNP) is a HMO-SNP plan with a Medicare contract and a contract with the Pennsylvania Medicaid program. Enrollment in Keystone First VIP Choice (HMO SNP) depends on contract renewal. This information is not a complete description of benefits. Call Member Services at 1-800-450-1166 (TTY/TDD 711), 8 a.m. to 8 p.m., 7 days a week, for more information. The formulary, pharmacy network and/or provider network may change at any time. You will receive notice when necessary. You must continue to pay your Medicare Part B premiums, unless otherwise covered by your Pennsylvania Medicaid benefits.